Thinking the Unthinkable: Six (Uncomfortable) Questions about the Swine Flu Outbreak

The word pandemic comes from Greek roots meaning "all the people." Not surprisingly, the first known medical reporter to file a story about a flu epidemic was Hippocrates around 412 BC. For centuries, flu disasters have struck just as naturally and inevitably as tsunamis, earthquakes, and hurricanes. Indeed, over the past 300 years, there have been 10 major flu pandemics (an average of 22 years apart), according to the Center for Infectious Disease Research and Policy (CIDRAP) at the University of Minnesota. Experts believe we're well overdue for another pandemic.

It's too soon to tell if this swine flu outbreak will turn into a pandemic, but the World Health Organization (WHO) has raised its pandemic alert level from 3 to 4 (on a scale of 6 being the worst). The swine flu outbreak has taken a "significant step" toward becoming a pandemic, but "we're not there yet," says Dr. Keiji Fukuda, assistant director-general for health, security, and environment at the WHO.

A lot has changed since the devastating Spanish Flu pandemic just 91 years ago when an estimated 50 million died around the world. Back then, most scientists believed mistakenly that the flu was caused by bacteria. Back then, there were no antiviral drugs to combat the flu, let alone antibiotics, which were developed in the 1940s. Back then, there were no jet airplanes that could cross the world (and spread the virus to every continent) in a single day. In the intervening years, a lot of progress has been made preparing for the inevitability of another pandemic. WHO launched its flu surveillance program in 1947. Vaccines and antiviral drugs are stockpiled around the world. But will all that be enough? We'll get to the scary answer to that question at the end of this article.

2. Are there enough antiviral medicines to keep us safe?

Walgreen purchasing managers met last weekend to make sure they're ready for a spike in demand for personal hygiene products like face masks and hand sanitizers. No surprise, there's also a run on antiviral medications. That's because the government says the swine flu strain is treatable with two antiviral drugs: Tamiflu (oseltamivir) and Relenza (zanamivir). Manufacturers of both drugs - Roche based in Switzerland and GlaxoSmithKline based in London - say they're increasing production.

The US government has stockpiled enough antiviral treatments to take care of 50 million people while different states have 22 million treatment courses. Homeland Security Secretary Janet Napolitano says the government will release 25 percent of its emergency stockpiles -- some 12 million doses - of Tamiflu and Relenza to various states just in in case.

If it needs to ramp up significantly, Roche, for instance, has an annual production capacity of 400 million treatment courses, according to the company.

3. How long will it take to create a new vaccine?

Baxter International, manufacturer of flu vaccines, has already requested samples of the swine flu virus to begin work on a vaccine. On a fast track, it will take between four to six months to create and distribute a new vaccine. On a global level, if a pandemic strikes this year, according to CIDRAP, manufacturers could produce 2.5 billion doses of vaccine in the first 12 months, but it would take four years to produce enough vaccine to meet total global demand.

4. Do face masks protect against swine flu?

They're the instant symbol of the outbreak, but do they work? Snug-fitting medical masks approved by the FDA - like dental or surgery masks - are better than nothing if you need to come in close contact with infected people or you're in crowded situations, but the CDC says that information on their effectiveness masks is limited.

"The risk for infection can be reduced through a combination of actions," the CDC says. "No single action will provide complete protection, but an approach combining the following steps can help decrease the likelihood of transmission. These actions include frequent hand-washing, covering coughs, and having ill persons stay home, except to seek medical care, and minimize contact with others in the household. Additional measures that can limit transmission of a new influenza strain include voluntary home quarantine of members of households with confirmed or probable swine influenza cases, reduction of unnecessary social contacts, and avoidance whenever possible of crowded settings."

The CDC continues: "When it is absolutely necessary to enter a crowded setting or to have close contact with persons who might be ill, the time spent in that setting should be as short as possible. If used correctly, facemasks and respirators may help reduce the risk of getting influenza, but they should be used along with other preventive measures, such as avoiding close contact and maintaining good hand hygiene."

5. How deadly is pandemic flu?

Every year in the US, between five to 20 percent of us are infected with the old-fashioned flu; 200,000 of us end up in the hospital; and around 36,000 of us die. Flu victims are typically the very young, the very old and the very immune-suppressed or ill.

"During the worst week of the 2007-2008 season, the regular flu had a mortality rate of about nine percent," according to a blog by Amanda Ripley, author of The Unthinkable: Who Survives When Disaster Strikes - and Why. By comparison, Ripley writes, one study of swine flu outbreaks showed a fatality rate around 14 percent.

The mortality rate of the Spanish flu pandemic of 1918 was 2.5 percent, according to The Daily Telegraph, while the mortality rate of the 1957 and 1968 pandemics was 0.5 percent. (The dreaded Ebola virus, for comparison, has a mortality rate that can reach 90 percent).

Obviously, the flu isn't a death sentence - far from it - but the body count escalates in a pandemic because so many millions are infected.

So, what goes wrong when younger, healthier people die from the flu? The key is something called the "cytokine storm," according to Dr. Michael Osterholm, director of CIDRAP. In a fascinating November 2005 online interview with The Washington Post, Osterholm explained: "A cytokine storm is the release of a chemical in the body that stimulates the human immune system to respond to the virus infection. In these serious illnesses and deaths, it's actually been an over vigorous immune response elicited by this infection that result in the organ damage and ultimately the death of the individual. Ironically this means that those with the strongest immune systems may be at highest risk for a serious outcome if infected with the (bird flu) H5N1 virus. At the same time, it is surely possible that those with weakened or immature immune systems, such as the very young or very old, and those with underlying immune conditions, may experience serious illness associated with the annual influenza illness, which often involves damage to the respiratory tract and subsequent secondary bacterial infection."

6. Is the world ready for a new pandemic?

In his online interview with the Post, Dr. Osterholm says that despite a lot of progress, the world still isn't very well prepared for pandemic. "The vast majority of the 6.5 billion people on the face of the Earth today do not have any access to intensive care or medicine," he says. "In addition, for most of the developed world, we too will not have access to mechanical ventilators, drugs, or other medical interventions that we might expect. We have little to no surge capacity or the ability to care for large numbers of new illnesses in any of our healthcare facilities today."

"For example," Osterholm says, "in the United States, we only have 105,000 mechanical ventilators in our hospitals. Today an average of more than 80,000 ventilators are in use every day and during the regular influenza season we find almost all of the 105,000 mechanical ventilators in use. Our national strategic stockpile maintained by the federal government has only an additional 4,500 mechanical ventilators for use in an emergency. We will run out of mechanical ventilators overnight. This is true for many of our antibiotics and antiviral drugs, as many of these are made outside of the United States in a single plant and where the raw ingredients needed to make the drugs come from many other countries."

Dr. Osterholm goes on: "With the first onset of pandemic influenza, I believe many of our borders will be closed to transportation and commerce and in this global just-in-time economy, many essential products and services will disappear overnight. ...The only things they will have left to protect themselves will be respirator masks. Again, because of the global just-in-time economy where two companies own a very large percentage of the international market share for production and sales of masks, and which have virtually no surge capacity for production, we will soon also run out of them. Finally, our hospitals, which are now operating in an almost constant full capacity, will not be able to handle the surge of patients with influenza. Therefore already many communities are planning for the care of these patients in auditoriums, gymnasiums, and even arenas where many cots can be lined up in endless rows. When one considers the above information, how can anyone think that this will be a whole lot different than?"

(Bonus) 7: Should you be scared?

Over the last few years, I've interviewed hundreds of the world's most effective survivors and thrivers. Many of the members of the Survivors Club share an outlook - a mentality - and an approach to dealing with crisis. Sure, they get scared (and freaked out) too. But they turn fear and anxiety into motivation and purpose. They confront all kinds of adversity with a mixture of realism and optimism. They seek out information; they adapt to new challenges; they make Plan and Plan B; and they take action.

No one in the world wishes or wants this swine flu outbreak to morph into a full-fledged pandemic with mass casualties. But it's absolutely essential to think the unthinkable and, given the nature of a pandemic threat, to be as well prepared and self-reliant as possible.

From The Washington Post online, Dr. Osterholm gets the last words: "The potential for pandemic influenza to be a catastrophic event in our human history is just too great of a risk for us to wait until the night before to get prepared. While this may all sounds scary to those reading this, our job in public health today is not to scare you out of your wits, but to scare you into your wits. We need you to let your federal, state, and local leaders, including those both elected and in the private sector, know that planning at the international, national and local level must be one of our highest priorities."

For more information about swine flu or surviving other kinds of life-changing adversity, please go to The Survivors Club Website.